Use of a Digital Cognitive Aid in the Early Management of Simulated War Wounds in a Combat Environment, a Randomized Trial.

INTRODUCTION: The French army has implemented an algorithm based on the acronym "MARCHE RYAN," each letter standing for a key action to complete in order to help first care providers during emergency casualty care. On the battlefield, the risk of error is increased, and the use of cognitive aids (CAs) might be helpful to avoid distraction. We investigated the effect of using a digital CA (MAX, for Medical Assistance eXpert) by combat casualty care providers on their technical and nontechnical performances during the early management of simulated war wounds, compared to their memory and training alone. MATERIALS AND METHODS: We conducted a randomized, controlled, unblinded study between July 2016 and February 2017. This study was approved by the Ethics Committee of the Ethical Board of Desgenettes Army Training Hospital (14.06.2017 n°385) and was registered on clinicaltrials.gov (NCT03483727). It took place during medicalization training in hostile environment ("MEDICHOS") in Chamonix Mont-Blanc and in the first aid training center in La Valbonne military base (France). Each participant had to deal with two different scenarios, one with MAX (MAX+) and the other without (MAX-). Scenarios were held using either high-fidelity patient simulators or actors as wounded patients. The primary outcome was participants' technical performance rated as their adherence to the MARCHE RYAN procedure (maximum 100%). The secondary outcome was the nontechnical performance according to the Ottawa crisis resource management Global Rating Scale (maximum 42). RESULTS: Technical performance was significantly higher in the MAX+ scenarios (70.60 IQR [63.70-73.56] than in the MAX- scenarios (56.25 IQR [52.88-62.09], p = 0.002). The Ottawa scores were significantly higher in the MAX+ scenarios (31.50 IQR [29.50-33.75]) than in the MAX- scenarios (29.50 IQR [24.50-32.00], p = 0.031). CONCLUSIONS: The use of a digital CA by combat casualty care providers improved technical and nontechnical performances during field training of simulated crises. Following recommendations on the design and use of CA, regular team training would improve fluidity in the use and acceptance of an aid, by a highly drilled professional corporation with a strong culture of leadership. Digital CA should be tested at a larger scale in order to validate their contribution to real combat casualty care.

Impact of Minor Surgery Emergencies in Isolated Sea-Based Environment: The French Navy Experience.

INTRODUCTION: The aim of this article is to determine whether some of the urgent (<24 hours) medical evacuations (MEDEVACs) (from French Navy surface ships in isolated situations but with an embarked medical officer) of patients suffering from minor surgical emergencies could have been avoided, and if so, which ones. MATERIALS AND METHODS: This was a retrospective descriptive study of all MEDEVAC's performed between 2009 and 2014. This was done by an analysis of the records held at the French Naval Medical Headquarters that included both MEDEVAC signals and anonymized files called "Patient Movement Request." RESULTS: 560 MEDEVACs were performed from French Navy surface ships which most had an embarked medical officer but which were in isolated situations. Only 34 (6.1%) of the total evacuations were suffering from minor surgical emergencies. The majority of these were nonurgent MEDEVAC's of whom 17 (50%) had no surgical procedure attempted on board. Seven (20%) underwent urgent MEDEVAC and only 2 of them had undergone the indicated therapeutic procedure on board. The most common pathology was displaced fracture of the fifth metacarpal (29.4%) before deep abscess (17.6%). CONCLUSION: Contrary to our initial expectation, the operational impact of minor surgical emergencies remains low, which might suggest that a French naval medical doctor's training is sufficient in this particular field. However, 50% of the overall evacuated patients and 71% of the "urgent" MEDEVACs (<24 hours) did not undergo the indicated, simple surgical procedure before evacuation. The idea of introducing a specific training program for these procedures may therefore still have value.

Bilateral pneumothoraces following acupuncture.

A 50-year-old woman was brought to the emergency department with shortness of breath and chest tightness following acupuncture to her upper back for a chronically painful left shoulder. She had symptoms of respiratory distress and chest X-ray revealed bilateral pneumothoraces. Symptoms resolved after insertion of bilateral Seldinger chest drains. She was admitted to the Cardiothoracic Surgery ward, chest drains were removed on the second and third days and the patient was discharged from hospital after 3 days. Clinicians and acupuncturists should be aware of this adverse event following acupuncture.

Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review.

OBJECTIVE: To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation. BACKGROUND: Animal studies suggest that the pathophysiology and physical signs of tension pneumothorax differ by subject ventilatory status. METHODS: We searched electronic databases through to October 15, 2013 for observational studies and case reports/series reporting clinical manifestations of tension pneumothorax. Two physicians independently extracted clinical manifestations reported at diagnosis. RESULTS: We identified 5 cohort studies (n = 310 patients) and 156 case series/reports of 183 cases of tension pneumothorax (n = 86 breathing unassisted, n = 97 receiving assisted ventilation). Hypoxia was reported among 43 (50.0%) cases of tension pneumothorax who were breathing unassisted versus 89 (91.8%) receiving assisted ventilation (P < 0.001). Pulmonary dysfunction progressed to respiratory arrest in 9.3% of cases breathing unassisted. As compared to cases who were breathing unassisted, the adjusted odds of hypotension and cardiac arrest were 12.6 (95% confidence interval, 5.8-27.5) and 17.7 (95% confidence interval, 4.0-78.4) times higher among cases receiving assisted ventilation. One cohort study reported that none of the patients with tension pneumothorax who were breathing unassisted versus 39.6% of those receiving assisted ventilation presented without an arterial pulse. In contrast to cases breathing unassisted, the majority (70.4%) of those receiving assisted ventilation who experienced hypotension or cardiac arrest developed these signs within minutes of clinical presentation. DISCUSSION: The reported clinical presentation of tension pneumothorax depends on the ventilatory status of the patient. This may have implications for improving the diagnosis and treatment of this life-threatening disorder.

Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis.

BACKGROUND: Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted. METHODS/DESIGN: We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series). DISCUSSION: This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.

Carbon monoxide poisoning in tents--a review.

This review discusses the overlooked problem of carbon monoxide (CO) poisoning within small tents. It summarizes previous case reports, reviews the toxicity of CO, and attempts to draw conclusions from experimental work. Finally, practical recommendations are developed on avoiding CO poisoning within tents. The term carbon monoxide was used in a search of the Medline database covering the years 1966 to 2003. The results were combined with the terms atmosphere or camps or stoves or climbs or mountains or tents or poisons. The resulting articles were reviewed, and those relevant to this problem were obtained. Hard copies were hand searched for further relevant articles until no more citations could be found. Three original articles were impossible to obtain but have been cited to assist others seeking to find them. Other data and articles were obtained from the Ministry of Defence but are unpublished for security reasons.

Comparison of carbon monoxide levels during heating of ice and water to boiling point with a camping stove.

OBJECTIVES: To determine whether using a camping stove to bring a pan of ice to boiling point produces higher carbon monoxide (CO) concentration than would bringing a pan of water to boiling point. The hypothesis was that ice would cause greater CO concentration because of its greater flame-cooling effect and, consequently, more incomplete combustion. METHOD: This was a randomized, prospective observational study. After an initial pilot study, CO concentration was monitored during 10 trials for each of ice and water. A partially ventilated 200-L cardboard box model was developed and then used inside a chamber at -6 degrees C. Ice temperature and volume, water temperature and volume, pan size, and flame characteristics were all standardized. Temperature of the heated medium was monitored to determine time to boiling point. Carbon monoxide concentration was monitored every 30 seconds for the first 3 minutes, then every minute until the end of each 10-minute trial. RESULTS: There was no significant difference (P > .05) in CO production levels between ice and water. Each achieved a similar mean plateau level of approximately 400 ppm CO concentration with a similar rate of rise. However, significantly higher (P = .014) CO concentration occurred at 4 and 5 minutes when the flame underwent a yellow flare; this occurred only on 3 occasions when ice was the medium. CONCLUSION: There were no significant differences for CO production between bringing a pan of ice or water to boiling point. In a small number of ice trials, the presence of a yellow flame resulted in high CO concentration. Yellow flares might occur more often with ice or snow melting, but this has not been proven.

Does pan diameter influence carbon monoxide levels during heating of water to boiling point with a camping stove?

OBJECTIVES: To determine whether pan diameter influences carbon monoxide (CO) concentration during heating of water to boiling point with a camping stove. The hypothesis was that increasing pan diameter increases CO concentration because of greater flame dispersal and a larger flame. METHOD: This was a randomized, prospective study. A Coleman Dual Fuel 533 stove was used to heat pans of water to boiling point, with CO concentration monitored every 30 seconds for 5 minutes. The stove was inside a partially ventilated 200-L cardboard box model that was inside an environmental chamber at -6 degrees C. Water temperature, water volume, and flame characteristics were all standardized. Ten trials were performed for each of 2 pan diameters (base diameters of 165 mm [small] and 220 mm [large]). RESULTS: There was a significant difference (P = .002) between the pans for CO levels at each measurement interval from 60 seconds onward. These differences were markedly larger after 90 seconds, with a mean difference of 185 ppm (95% CI 115, 276 ppm) for all the results from 120 seconds onwards. CONCLUSION: This study has shown that there is significantly higher CO production with a large-diameter pan compared with a small-diameter pan. These findings were evident by using a camping stove to heat water to boiling point when a maximum blue flame was present throughout. Thus, in enclosed environments it is recommended that small-diameter pans be used in an attempt to prevent high CO levels.

Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea

Diarrhoea is the most common illness affecting travellers to developing countries. Our study was designed to compare the efficacy of a single 500 mg dose of ciprofloxacin with placebo for treatment of acute diarrhoea in travellers. British troops who were within their first 8 weeks of deployment in Belize and who presented within 24h of the onset of diarrhoea, were randomised to receive either ciprofloxacin 500 mg or placebo. Every subject recorded the number and consistency of stools and presence of any other associated symptoms for 72 h or until recovery. Of 88 subjects enrolled, 83 were evaluable, of whom 45 received ciprofloxacin and 38 placebo. Groups did not differ with regard to duration or severity of diarrhoea at randomisation. Mean (SE) duration of diarrhoea, as assessed by time to the last liquid and last unformed stool, was reduced from 50.4 (4.5) h and 53.5 (4.4) h, respectively, in the placebo group to 20.9 (3.4) h and 24.8 (3.8) h in those receiving ciprofloxacin (p<0.0001). Mean number of liquid stools was reduced from 11.4 (1.2) in the placebo group to 5.0 (0.7) in the ciprofloxacin-treated group (p<0.0001). The cumulative percentages of subjects with no unformed stool after 24 h, 48 h, and 72 h were, respectively, 64 percent, 82 percent, and 93 percent in the ciprofloxacin group and 11 percent, 42 percent, and 79 percent in the placebo group (p<0.0001, p<0.001, and not significant, respectively). A single 500 mg dose of ciprofloxacin was an effective empirical treatment for reducing the duration and severity of diarrhoea in travellers. The regimen should maximise compliance and reduce the cost and duration of therapy (AU)